STATE OF ILLINOIS

IN THE CIRCUIT COURT OF THE _____ JUDICIAL CIRCUIT

______________________ COUNTY

IN RE THE MATTER OF:

________________________________
CHANGE OF NAME TO:
_________________________________

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No. __________________________

PETITION FOR CHANGE OF NAME

I, ________________________________, without the assistance of counsel, ask this Court to enter an
order for change of name in compliance with 735 ILCS 5/21-101 et. seq. In support of my Petition, I
state the following items are true:
1. This Court has jurisdiction over the subject matter and my person.
2. I am ____ years of age.
3. My current address is ___________________________________________________________.
4. I have lived in Illinois since _________________________________________________.
5. I have never been convicted of criminal sexual abuse of a minor, sexual exploitation of a child,
indecent solicitation, or any other crime which would require registration as a sex offender in this
or any other state.
6. I have never been convicted of identity theft or aggravated identity theft in this or any other state.
7. I have ______ never been convicted of a felony in this or any other state; I was convicted of a
felony but _____ was pardoned _____ ten years or more years have passed since completion and
discharge of my sentence.
8. The state/country of my birth is _________________________________.
9. My current full name is _______________________________________.
10. The new name which I would like the Court to give me is _______________________________
___________________________.
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I hereby certify, under penalties as provided by law pursuant to Section 5/1-109 of the Code of Civil
Procedure, that all statements set forth in this petition are true and correct to the best of my knowledge
and belief.
WHEREFORE, I request that the Court grant my Petition for a Change of Name.
____________________________________
Signature of Petitioner
____________________________________________________________________________________
AFFIDAVIT OF NON-PETITIONING WITNESS
I, _____________________________________________________ affirm under oath that I am
acquainted with the petitioner _______________________________________________.
I have read and understood the contents of this petition, and affirm that all statements therein are true
and correct to the best of my knowledge and belief.
____________________________________
Signature of Witness
Subscribed and sworn before me on this ______ day
of _________________, the year __________
_______________________________
Notary Public

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